PATIENT INFORMATION ASSESSMENT MANAGEMENT NURSING CARE PLAN

Room #: General Appearance: Neuro: Active Medications

Date of Admit: 1. Nursing Diagnosis 1
Gender: 2.
DOB: 3.
Cardio: 4. Interventions
Ht: Wt: 5. 1.
6. 2.
Code Status: 7. 3.
Respi: 8. 4.
Allergies: IV access: 9.
IV Fluid: 10.

VITAL SIGNS GI: BM: Diet:

Admitting Diagnosis: 0800 1200 1600 2000 Nursing Diagnosis 2

GU:
Interventions
Current Diagnosis: Nutrition status: 1.
2.
Musculo: 3.
4.

Integ: Activity Level:

Nursing Diagnosis 3

Date
Time Interventions
PR 1.
bmp
RR
pm
BP
mmHg
Temp

O2
%
Pain
1-10
Pertinent Patient History Laboratory Diagnostics: Planned Surgical
Procedures/Consultation:
WBC
Hgb
 Hct
Plt
Rehab/Discharge needs:
Na
K+
BUN
Cr
Mg+
NSG 245A SBAR Worksheet